NEW YORK (Reuters Health) - Screening can identify
early-stage hepatocellular carcinoma (HCC) in patients with
chronic liver disease, but whether screening yields a survival
advantage over clinical diagnosis is uncertain, new research
suggests.

"While we say that the strength of evidence is very low, we
don't recommend against screening," said principal investigator
Dr. Devan Kansagara of the Portland Veterans Affairs Medical
Center in Portland, Oregon, by phone with Reuters Health. "We
just clarify the strength of evidence. This is an important
distinction."

"Whether or not patients should be screened depends on many
things. . . . It's important to make sure that the program
targets the higher-risk people and avoids people who might not
benefit from screening. We hope clinicians will discuss clinical
care and share decision making with their patients," he said.

To better understand the benefits and harms of routine HCC
screening compared with clinical diagnosis in patients with
chronic liver disease, the authors reviewed the published
English-language clinical trials and observational studies and
reported their findings online June 17 in Annals of Internal
Medicine.

Of 13,801 citations, the authors eliminated studies that did
not meet their inclusion criteria, such as those of patients
with prior, advanced, or metastatic HCC, and chose 22 primary
studies. They found that the overall strength of evidence on the
effects of screening was very low.

Co-author Dr. Janice H. Jou, also of the Portland Veterans
Affairs Medical Center, said by phone, "There is not adequate
level-1 evidence published in the literature to be able to draw
a conclusion."

"There are very few randomized trials in this area. The
biggest opportunity presented by our findings is to create
opportunities for future study in this area. It's a way to start
a conversation and a discourse about what are the next steps to
investigate this area," she said.

"Patients who have early stage disease can be treated with
very effective therapies and their overall survival can be
improved. We should do better studies to identify who those
patients are," she said.

Dr. Yuman Fong of City of Hope in Duarte, California, said
by phone, "I don't think our screening methods now are perfect,
and I don't think most of our small tumors are being treated
correctly. That's why, when you look at the studies over a long
period of time, the conclusion is that it probably didn't change
very much. It doesn't surprise me."

"In reality, in the best of medical worlds that we currently
already have the technology for, we would be picking those
people at high risk, screening them with a short-sequence scan
that can find cancer and distinguish it from the non-cancerous
nodules and either laparoscopically or robotically remove small
pieces of liver for the cancer or kill it with a needle as an
outpatient procedure," he said.

"It is not right to not screen," he added. "The chance of
finding cancer is very high in this patient population: 5% per
year of cancer. The questions are how to screen and how to treat
the cancer once you find it. These are the bigger questions, not
whether we should screen or not."

"It is important for these people to be seen and blood tests
to be drawn because now our treatments for hepatitis B and C are
so good," he said.

Dr. Fong, who was not involved in the study, advised that
"we should be designing selective scan sequences that take less
time on the scanner, are less taxing to the patients and less
costly. The cost has been stopping us from using the best
technology we have. We're using sonography because it's much
lower cost."

In an editorial, Drs. David Atkins, David Ross and Michael
Kelley of the Veterans Health Administration in Washington, DC,
write, "Although we agree that current screening should not be
expanded and new screening programs should not be initiated, the
range of uncertainty includes a clinically important benefit of
screening."

They write that, in the highest-risk patients, including
those with hepatitis C cirrhosis, screening has a much greater
potential to produce benefits that exceed harms than it does in
the general population.

"It is appropriate to allow clinicians caring for these
patients to continue to offer screening, but offers should be
targeted to those who are good candidates for treatment and
should include a shared decision-making approach that explicitly
acknowledges the limitations of the evidence," they write.